Julie Casani

Where were you on 9/11? Were you part of the emergency response?

I was the bioterrorism coordinator for Maryland and deployed to the state emergency operations center. We were concerned in the National Capitol Region that the plane crashes were laced with chemical or biological weapons (“chem/bio”). We were also concerned that a secondary chem/bio attack would occur. So, we were very much on alert. We were directly involved with the Pentagon and Pennsylvania crash sites as well.

What was your introduction to public health preparedness? How did you get involved with PHEP?

I was involved with a team doing a 120-city training for weapons of mass destruction (WMDs) in the 1990s and, being in Maryland, the mustard demilitarization program. So, I was already engaged in preparedness for chem/bio incidents before 9/11.

I think modern public health preparedness started with the anthrax events of 2001. This is when public health was seen as the lead response agency. The response relied on the core public health functions of outbreak response. How we adapt outbreak response to a large-scale event is the difference between public health preparedness and public health.

What do you do on a day-to-day basis related to PHEP activities?

After my time in Maryland and then in North Carolina as the PHEP director, I left government work to go to North Carolina State University. I am not currently working on anything directly related to PHEP, but I am running a mini health department on campus for COVID-19 response.

Additionally, now I teach, lecture, and mentor regarding public health response and disaster epidemiology. I feel obligated to provide that perspective to the next generation of responders. They will have the technology and the infrastructure built, but it’s critical that they know where it comes from and where the science should be.

Over your career, what changes have you seen in PHEP? How has public health preparedness evolved?

The most important change is who actually does public health preparedness. When I first started, there was acknowledgement that public health had been doing response of some kind for hundreds of years. However, I learned that the organization of the response was “new,” and we would need to collaborate with agencies that we had never worked with. We implemented a new organizational structure. We struggled to get what we felt was our due respect and authority. I remember how we would argue that it was important enough to be in the Secretary of Health’s office and yet it rarely was. Then we went about our business for years advising, but going unnoticed by, the highest leadership.

Interestingly, by the time we got to COVID-19, two things happened:

1. After many responses (e.g., anthrax, SARS [1], H1N1, Ebola, and a few major environmental events), coordinating surveillance, testing, nonpharmaceutical interventions, and mass vaccination became “easy” (not to minimize the work at all).
2. Having established the public’s expectations for accountability, response coordination was at the highest levels of leadership. The tactical and operational response was more planned for and ingrained, but the leadership and policy side were more complex.

 How has PHEP supported preparedness in your jurisdiction? What’s the most significant impact PHEP has made in terms of your jurisdiction’s ability to respond to a public health threat?

The biggest impact of PHEP was the capabilities in place now. As an “outsider,” it is gratifying to see so much of what we developed, implemented, and practiced being put into place for the COVID-19 response. It was an honor to see the people I worked with take over and do such a great job. I know, having been there, that the leadership had a great staff behind them. Working with my local health department, I knew that so many of their successes were built during the time that I worked at the state level. It’s great knowing I was a part of that.

Reflecting on your career in public health emergency preparedness, what accomplishments are you most proud of?

From a system perspective, I am most proud that preparedness has shown its value. I think there were many things that COVID-19 illustrates as “pay-offs” of years of investment: collaboration, implementation of vaccine programs, and having existing plans that we can now use, such as scarce resource plans and ethical use frameworks. These things take time and processing, and you can’t do them during an emergency.

From a personal perspective, I was able to effectively manage a response for a campus of 45,000 people because of the relationships and expertise that I had built over the 20 years of my career. Things went relatively well because I was able to leverage those things and apply them in a supportive environment.

Other than COVID-19, what public health emergency response experience stands out in your memory and why?

Anthrax stands out because we didn’t have a plan, relationships, or staff. We worked with the system of local health departments in Maryland and mobilized what we did have (e.g., using antibiotics from the sexually transmitted disease [STD] clinics until we got resupplied from the Strategic National Stockpile).

We had supportive leadership at the state health department (Dr. Georges Benjamin). Our response to this unique event was very satisfying and educational. It taught me about resiliency, leadership, policy versus science, and capacity versus capability. When I look back on what we did and how I am amazed and impressed. We distributed more than 30,000 courses of antibiotics, answered hundreds of “white powder” calls a day, and developed clinical guidance when the science was inconclusive. Although any loss of life is sad, there were only five deaths. It’s pretty remarkable.

How do you maintain momentum and prevent personal burnout in the preparedness field? How do you do the same for your team? When I was at the state, I surrounded myself with a great team. We cross-trained so that we could step in for each other when needed. This was key.

I don’t have that depth in my current work. As an emergency medicine clinician, I’ve learned to compartmentalize and defer “downtime.” COVID-19 was difficult.

The biggest thing I missed was the collaboration. In public health, there was a small, close group that talked about decisions and worked through things. Now I’m on a nonmedical campus and don’t have that support. It was very lonely.

Most importantly, I’ve learned that every response has a rhythm—uncontrolled chaos then routine chaos. After the chaos, you feel lost because you find that you don’t need to be doing six things at once. There is anxiety from this and a bit of a letdown. That passes and then you feel “normal” again.

If you have put off your reactions, this is when they bubble up, and it’s not uncommon to be emotional, angry, empty, sad, or happy for no apparent reason. As long as you know it’s going to happen and those around you know you’re OK, you’re OK. It’s just you processing what you’ve been through. This is usually when I take long walks, binge-watch TV shows, and am most productive at my craft habits.